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STATEMENT OF POLICY
Health in All Policies
Policy
Health in All Policies (HiAP) is a change in the systems that determine how policy decisions are
made and implemented by local, state, and federal government agencies to ensure that policy
decisions have beneficial or neutral impacts on the determinants of health. HiAP strategies are
meant to ensure that all policies and services from all sectors have beneficial or neutral impacts
on the determinants of health.1 The National Association of County and City Health Officials
(NACCHO) recommends distinct roles and responsibilities for different agencies to advance the
use of HiAP.
Federal, state, and local government agencies should conduct the following activities:
 Adopt a HiAP approach in the policy-making process in order to ensure that policies
made outside of the health sector have positive or neutral impacts on the determinants of
health.
 Provide funding, training, and technical assistance for local health departments to ensure
that they can assume a leadership role implementing a HiAP approach at the local level
and determine the best strategies for implementing HiAP locally. These investments
should be made early in the process because time and funding are necessary to build the
capacity to generate cross-agency collaboration before work begins on any program or
project development.
 Facilitate cross-sector partnerships through enhanced communication and collaboration
between agency leadership.
 Identify and showcase successful examples of cross-agency work, from within and
across sectors, and provide models for collaboration.
 Establish a consistent evaluation framework for local health departments to use to
identify long-term goals and strategies and ascertain progress toward them over time.
Local health departments should conduct the following activities:
 Foster political will at the decision-maker level and work upstream and downstream to
implement a HiAP approach.
 Develop metrics of success to use in negotiating cross-agency collaborative processes
and work to translate public health data and terminology for other sectors.
 Take a leadership role to implement HiAP at the local level, including identifying the
best strategies for implementing HiAP in the local health department jurisdiction.
 Educate local, state, and federal policymakers about the value of HiAP.
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Develop metrics and milestones to measure the effects of a HiAP approach or policy on
health outcomes. Successful initiatives have been able to tie funding to a shared set of
metrics for evaluating success.
Engage a wide variety of partners from the non-health sector whose work influences the
social determinants to health to effect improvements in health outcomes through a
collective impact model.
Participate in or lead health impact assessments (HIAs) as a way to influence non-health
sector decisions that have health impacts. HIA can be used as a tool to implement a
HiAP approach and to educate policymakers.
Justification
HiAP is a strategy that assists leaders and policymakers in integrating considerations of health,
well-being, and equity during the development, implementation, and evaluation of policies and
services. HiAP is a strategy that explicitly addresses decisions made outside the health sector that
significantly impact public health. Ensuring that health is considered in the policy formulation
process creates opportunities for policy decisions to achieve the non-health agency mission and
minimize or improve the policy’s impact on health.2 Public health literature has identified seven
interrelated strategies for incorporating HiAP into decisions and systems: (1) developing and
structuring cross-sector relationships; (2) incorporating health into decision-making processes;
(3) enhancing workforce capacity; (4) coordinating funding and investments; (5) integrating
research, evaluation, and data systems; (6) synchronizing communications and messaging; and
(7) implementing accountability structures.7
Policy decisions made outside the health sector impact the determinants of health.
Researchers and policymakers are increasingly recognizing that health is determined by more
than just healthcare.3 For example, recent research suggests than only 10%of health is
determined just by healthcare itself.4 The determinants of health also include personal, social,
economic, and environmental factors that greatly influence risk for injury, disease, and stress.
The determinants of health can be divided into individual behavior, genetic predisposition, social
factors, healthcare, and environmental exposure. Local health departments have focused
increasingly on policymaking either to directly impact population health (e.g., prohibiting transfats in prepared foods) or to change the environment to support healthier choices (e.g., tobacco
taxes).
Many of the social factors that determine health are largely influenced by measures that are often
managed by government sectors other than the public health sector. 2 The social determinants of
health, for example, include factors like the quality of schools; socioeconomic conditions, such
as poverty; transportation options; public safety; and residential segregation. These factors are
managed outside the health sector. For example, transportation options are shaped primarily by
Congress (through the transportation reauthorization); federal, state, and local departments of
transportation; metropolitan planning organizations; and citizens engaged in the planning
process.2
The same is true for the physical determinants of health, which include many of the factors
addressed by environmental public health practitioners. These factors include the natural
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environment, such as plants, weather, or climate change; exposures to toxic substances and
hazards; the built environment; worksites, schools, and recreation settings; and housing, homes,
and neighborhoods.2 While public health recognizes the importance of these physical
determinants of health, the decision-makers shaping these factors have policy goals that are
primarily unrelated to health. As a result, decisions shaping these physical determinants of health
are often made without consideration to their health impacts.
HiAP can be used at all levels of government and in the non-government sector. The creation of
the National Prevention, Health Promotion, and Public Health Council, formed after the passage
of the Affordable Care Act, is a strategy to achieve HiAP at the federal level. The Council
consists of federal agency heads that manage all sectors, not just health. These include, for
example, the Transportation, Labor, Education, and Justice departments. Chaired by the Surgeon
General, the Council has developed the National Prevention Strategy. According to the Strategy,
“prevention should be woven into all aspects of our lives, including where and how we live,
learn, work and play. Everybody—businesses, educators, health care institutions, government,
communities and every single American—has a role in creating a healthier nation.”5
The state and local levels can act in multiple ways to ensure participation in HiAP by all
agencies. At the local level, the institutionalization of HIAs has been cited as one strategy to
achieve HiAP. 6, 7 A National Research Council report on HIAs noted that although many local
health departments (e.g., Denver, Baltimore, Seattle, Portland, and Los Angeles) have been
leaders or participants in HIAs, only the San Francisco Department of Public Health has
incorporated HIA as a routine institutional practice.8 With adequate funding and support more
local health departments might choose to adopt this strategy.13
A wide variety of other strategies to achieve HiAP might be more suitable for some
jurisdictions.1 Because HiAP is still in an early stage of development in the United States, local
health departments can benefit from the experience of other local health departments, states, and
countries that have used different approaches to achieve HiAP. For example, the South
Australian Health Department uses a health lens analysis at the policy formulation stage in all
government agencies. Their approach is based on the recognition that “traditional HIA is most
effective when applied to an existing policy or proposal…with clear plans and proposals. On the
other hand, the HiAP health lens operates within a policy development environment where the
general policy intent is known but existing draft policies frequently don’t exist.”1 This approach
can be translated into local public health practice. For example, local health departments may
train sister agencies about how to assess potential policies using various health lenses. Local
health departments can also reframe health lenses to ensure that environmental public health and
health equity are in sharp perspective when non-health agencies form new policies. This
approach supports the development of healthy public policies and can be supplemented by
targeted HIAs (once a clear policy or plan is recommended).1
Public health surveillance may be combined with health lens analysis and HIA to create a
powerful change in the systems that shape the social and physical environment. For example, a
public works department, trained to use a health lens, may be required to inform the LHD when a
new policy is being formulated, the outcome of the health lens analysis, and the recommended
policy. This enables the LHD sufficient time to educate its community stakeholders, who, in
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turn, may recommend conducting an HIA if there is still concern that the recommended policy
does not address the community’s concerns about potential health impacts.
Ordinances and executive orders are two other strategies to achieve HiAP. For example, King
County’s Ordinance 2010-0509 defines the “just and fair” provisions of its countywide strategic
plan by specifying 14 determinants of equity that are clearly determinants of health. Moreover,
the ordinance directs the executive to “apply equity and social justice foundational practices to
county actions and endeavor to integrate these practices into the county's: strategic, operational
and business plans; management and reporting systems for accountability and performance; and
budgets in order to eliminate inequities and create opportunities for all people and
communities.”9 In 2014, Mayor Dwight C. Jones of the City of Richmond, Virginia, approved
the adoption of Resolution No. 2014-R262 “to adopt the Health in All Policies approach for the
City of Richmond in the form of a ‘Policy for HiAP Framework.’”10 The resolution commits the
City of Richmond “incorporate Health Considerations into division-making across all
departments and policy areas.”10 Local health departments can play a role in implementing
similar approaches in their jurisdictions by educating legislators and executives about the
successful efforts in King County and the City of Richmond.
Local health departments are best positioned to implement HiAP in their jurisdictions. LHDs can
choose from a variety of strategies that lead to HiAP, which they can implement as part of public
health practice. As an office or administrative unit of government responsible for the health and
well-being of a population smaller than a state, HiAP efforts are consistent with the 10 Essential
Services and the Operational Definition of a Local Health Department.11, 12 Given their mission
to protect public health, their traditional role as a convener, and connections to communities,
local health departments should be the sources of local leadership in HiAP. In addition, HiAP fits
with ongoing efforts to improve population health through policy, systems, and environmental
change strategies. Local health departments can decide whether and how to implement HiAP as a
part of community assessment and planning, thereby making HiAP implementation at the local
level a public health practice.
Funding agencies interested in supporting HiAP nationally can provide resources to local health
departments to implement HiAP while allowing them flexibility in determining appropriate
actions to achieve HiAP. Funding agencies have the opportunity to help implement HiAP
approaches nationally through the following actions:
 Funding local health departments to implement HiAP at the local level.
 Providing technical and other assistance to help local health departments implement HiAP
locally.
 Offering professional opportunities for local health department practitioners to educate
policy-makers at the local, state, and federal levels about HiAP.
Funding requirements should be sufficiently flexible to enable local health departments to pursue
HiAP in the way that fits best with the local situation. Funding for improving health lens analysis
to ensure adequate incorporation of environmental public health and health equity issues and the
latest science could also be valuable. Technical assistance could include case studies of HiAP
successes, educational materials about health lens analysis, and local health department staff
training about how other sectors make policy decisions. The direct experience of local health
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department practitioners implementing HiAP locally can provide valuable lessons for
implementing HiAP in other jurisdictions. In addition, it empowers local health department
practitioners in their efforts to educate policymakers about the value of implementing HiAP at
the state and federal levels. By supporting local health department professional activities
involving education and dissemination, funding agencies can have an impact on promoting HiAP
on a national scale. Ultimately, such a ground-up approach to HiAP may have the most enduring
impact on the determinants of health, since many decisions that shape the environment start at
the local level.
References
1.
Department of Health, Government of South Australia. (2010). Implementing Health in All Policies: Adelaide
2010. http://www.who.int/sdhconference/resources/implementinghiapadel-sahealth- 100622.pdf
2. Healthy People 2020. Assessed October 22, 2015, from
http://www.healthypeople.gov/2020/about/DOHAbout.aspx
3. Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on
the social determinants of health. Geneva: World Health Organization; 2008. Retrieved October 22, 2015, from
http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf [PDF - 4.3 MB]
4. Schroeder, S. (2007). We can do better—Improving the health of the American people. New England Journal of
Medicine, 357, 1221-1228.
5. Gase, L. N., Pennotti, R., & Smith, K. D. (2013). “Health in All Policies”: Taking stock of emerging practices
to incorporate health in decision making in the United States. Journal of Public Health Management and
Practice, 19(6), 529–540.
6. U.S. Surgeon General. National Prevention Strategy: Active Living webpage. Retrieved October 22, 2015, from
http://www.surgeongeneral.gov/priorities/prevention/strategy/active-living.html
7. Collins, J., & Koplan, J. P. (2009). Health impact assessment: A step toward health in all policies. Journal of
the American Medical Association, 302(3), 315–317.
8. National Research Council of the National Academies. (2011). Improving Health in the United States: The Role
of Health Impact Assessment. Washington, DC: The National Academies Press. Retrieved October 22, 2015,
from http://www.iom.edu/~/media/Files/Activity%20Files/Environment/EnvironmentalHealthRT/2011-NovRT/132291.pdf
9. King County, Washington. Retrieved October 22, 2015, from
http://www.kingcounty.gov/elected/executive/equity-social-justice.aspx
10. City of Richmond, Virginia City Council. Meeting Summary from Monday, January 12, 2015. Retrieved
October 9, 2015, from http://www.kathygraziano.com/documents/CC20150112MeetingSummary.pdf
11. Centers for Disease Control and Prevention. The Public Health System and the 10 Essential Public Health
Services webpage. Retrieved October 22, 2015, from http://www.cdc.gov/nphpsp/essentialservices.html
12. National Association of County and City Health Officials. (November 2005). Operational Definition of a
Functional Local Health Department. Retrieved October 22, 2015, from
http://www.naccho.org/topics/infrastructure/accreditation/upload/OperationalDefinitionBrochure-2.pdf
Record of Action
Proposed by NACCHO Environmental Health Committee
Approved by NACCHO Board of Directors
March 2012
Updated November 2015
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